What is the management approach for a patient with a positive Antinuclear Antibody (ANA) test and hyperhidrosis?

From the Guidelines

Management of a patient with a positive ANA test and hyperhidrosis requires addressing both conditions separately, as they are typically unrelated. For the positive ANA, further evaluation is necessary to determine clinical significance, including additional autoantibody testing, comprehensive history, physical examination, and possibly referral to a rheumatologist if symptoms suggest an autoimmune disorder, as recommended by 1 and 1. A positive ANA alone without symptoms may simply require monitoring. The use of a 1:160 dilution as the cut-off point for ANA detection is recommended, as it increases the positive likelihood ratio and diagnostic performance, with a specificity of 86.2% and sensitivity of 95.8% 1. For hyperhidrosis, first-line treatment includes aluminum chloride antiperspirants (20-25% concentration) applied nightly to dry skin. If ineffective, prescription options include glycopyrrolate (1-2mg orally twice daily), oxybutynin (5-10mg daily), or topical anticholinergics like glycopyrronium tosylate. For focal hyperhidrosis, botulinum toxin injections (50-100 units for axillae) provide 4-12 months of relief. Iontophoresis may help for palmar/plantar hyperhidrosis, using devices for 20-30 minute sessions several times weekly. Severe cases unresponsive to these treatments might require surgical options like sympathectomy. Lifestyle modifications including wearing breathable fabrics, avoiding triggers like spicy foods and caffeine, and stress management techniques should be recommended for all patients with hyperhidrosis. It is essential to note that the diagnosis of systemic autoimmune rheumatic diseases (SARD) requires a panel of specific laboratory tests, including ANA, anti-dsDNA, and anti-ENA antibodies, as stated in 1. The detection of ANA is the first level test for laboratory diagnosis of SARD, and ANA testing is primarily intended for diagnostic purposes, not for monitoring disease progression 1. The IIFA is the reference method for ANA screening, and alternative assays can be used while keeping in mind that false negative and false positive ratios of these methods may be different 1. Diagnostic laboratories should specify the methods used for detecting ANA when reporting their results, and tests based on a restricted mixture of defined nuclear antigens should not be referred to as ANA test or ANA screen 1. Each laboratory should verify the recommended cut-off for kits used to determine ANA, using age and gender-matched sera from healthy subjects from the general local population, with cut-offs defined as the 95th percentile 1. In case of a positive ANA test, it is recommended that the pattern and the highest dilution to demonstrate reactivity be reported, and ANA-IIFA patterns should be reported according to standardized terminology 1. Besides nuclear patterns, cytoplasmic and mitotic apparatus patterns should be reported and specified when possible, and if ANA result is positive, testing for anti-dsDNA antibodies is advised when there is clinical suspicion of SLE 1. For anti-dsDNA antibody determination, the Farr assay and the CLIFT offer high clinical specificity, and alternative methods may yield lower specificity, and if so, it is recommended that positive results obtained by these methods be confirmed by CLIFT or Farr assay—and be reported separately 1. The method used for anti-dsDNA antibody detection should be included in the test result, and results of anti-dsDNA antibody detection should be reported quantitatively (or semiquantitatively for CLIFT) 1. For monitoring of SLE disease activity by quantitative determination of anti-dsDNA antibodies, the same method should be used, and in case of a positive ANA test during the diagnostic work-up, it is recommended to perform specific tests for anti-ENA antibodies 1. For anti-ENA antibodies detection, the method used should be reported, and in the case of discrepancy with IIFA or with clinical suspicion, the use of an additional method should be considered, and results of assays for antibodies to specific ENA should be reported separately (including negative results) 1. Quantitative determination of positive anti-RNP antibodies is recommended in case of a clinical suspicion of mixed connective tissue disease, and in case of high clinical suspicion, the physician request for determination of antibodies to specific ENA should be granted, irrespective of the result of the ANA test 1. Each laboratory should verify the recommended cut-off for kits used to determine anti-dsDNA and anti-ENA antibodies, using an adequate number of samples from patients with the appropriate autoimmune diseases, disease controls, and healthy controls, with cut-offs defined using ROC curve analysis 1. In summary, the management of a patient with a positive ANA test and hyperhidrosis requires a comprehensive approach, including further evaluation of the positive ANA, treatment of hyperhidrosis, and consideration of lifestyle modifications, as well as adherence to the recommended guidelines for ANA testing and interpretation.

From the Research

Management Approach for Positive ANA and Hyperhidrosis

• The management approach for a patient with a positive Antinuclear Antibody (ANA) test and hyperhidrosis involves treating the hyperhidrosis symptoms, as there is no direct correlation between ANA and hyperhidrosis treatment.
• Hyperhidrosis treatment options include:
  • Topical solutions such as antiperspirant applications and aluminum chloride preparations 2
  • Iontophoresis 2
  • Botulinum toxin type A injections for severe primary axillary hyperhidrosis that failed conservative topical therapies 2, 3
  • Combination therapy with aluminum chloride hexahydrate in a salicylic acid gel base and botulinum toxin type A for moderate to severe hyperhidrosis 4
  • Topical glycopyrrolate for facial hyperhidrosis 5, 6
• The choice of treatment depends on the severity and location of the hyperhidrosis, as well as the patient's response to previous treatments.
• It is essential to note that the positive ANA test may indicate an underlying autoimmune condition, which should be evaluated and managed separately by a healthcare professional.

Treatment Options for Hyperhidrosis

• Botulinum toxin type A injections have been shown to be effective in reducing sweat production in patients with axillary hyperhidrosis 3
• Topical glycopyrrolate has been found to be effective in reducing sweat production in patients with facial hyperhidrosis 6
• Combination therapy with aluminum chloride hexahydrate in a salicylic acid gel base and botulinum toxin type A may be beneficial for patients with moderate to severe hyperhidrosis who have not responded to monotherapy 4

Considerations for Patients with Positive ANA

• Patients with a positive ANA test should be evaluated for underlying autoimmune conditions, such as lupus or rheumatoid arthritis.
• The treatment approach for hyperhidrosis in patients with a positive ANA test should be individualized, taking into account the patient's overall health status and any underlying conditions.